Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement From the Society of Hospital Medicine

Deciding Whether to Use Opioids During Hospitalization

1. SHM recommends that clinicians limit the use of opioids to patients with 1) severe pain or 2) moderate pain that has not responded to nonopioid therapy, or where nonopioid therapy is contraindicated or anticipated to be ineffective.

Opioids are associated with several well-recognized risks ranging from mild to severe, including nausea, constipation, urinary retention, falls, delirium, sedation, physical dependence, addiction, respiratory depression, and death. Given these risks, the risk-to-benefit ratio is generally not favorable at lower levels of pain severity. Furthermore, for most painful conditions, including those causing severe pain, nonopioid analgesics, including acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), have been demonstrated to be equally or more effective with less risk of harm than opioids.^9-13 Clinicians should consider drug–drug and drug–disease associations when deciding between these different therapies and make a determination in each patient regarding whether the benefits outweigh the risks. Often, drug–disease interactions do not represent absolute contraindications, and risks can be mitigated by adhering to dosage limits and, with respect to NSAIDs, 1) monitoring renal function, 2) monitoring volume status in patients with congestive heart failure, and 3) considering a selective cyclooxygenase-2 (COX-2) inhibitor rather than a nonselective NSAID or pairing the NSAID with an acid-suppressive medication in patients with a history of peptic ulcer disease or at elevated risk for gastroduodenal disease. For these reasons, a trial of nonopioid therapy (including pharmacologic and nonpharmacologic modalities) should always be considered before using opioids for pain of any severity. This does not imply that a trial of nonopioid therapy must be performed in all patients, but rather, that the likelihood of benefit and associated risks of opioid and nonopioid therapy should be considered for all patients in determining the best initial management strategy.

2. SHM recommends that clinicians use extra caution when administering opioids to patients with risk factors for opioid-related adverse events.

Several factors have been consistently demonstrated to increase the risk of opioid-related adverse events–most importantly, respiratory depression and overdose–in varied patient populations and settings, including age 65 years and older,^1,14-17 renal insufficiency,^1,14,18 hepatic insufficiency,^1,14 chronic respiratory failure (including chronic obstructive pulmonary disease, sleep apnea, etc.), and receipt of other central nervous system (CNS) depressant medications (including, but not limited to, benzodiazepines).^1,18-20 History of any substance use disorder and psychiatric disorders have been associated with an increased risk for the development of opioid use disorder.^21-24 These factors should be weighed against the benefits when deciding on opioid appropriateness in a given patient. However, identification of these risks should not preclude opioids as part of pain management. When a decision is made to use opioids in patients with these risk factors, clinicians should 1) use a reduced starting dose (generally, at least a 50% reduction in the usual starting dose) and 2) consider closer monitoring for adverse effects (eg, more frequent nursing assessments, capnography, or more frequent outpatient visits).

3. SHM recommends that clinicians review the information contained in the prescription drug monitoring program (PDMP) database to inform decision-making around opioid therapy.

Although data on the impact of use of the state PDMP database on prescribing practices or patient outcomes are limited, PDMP use has been advocated by multiple guidelines on acute pain management.^25-27 The PDMP provides information that can be useful in several ways, including 1) confirmation of prior opioid exposure and dosage, which should be used to guide appropriate dosage selection in the hospital, 2) identification of existing controlled substance prescriptions, which should be considered in prescribing decisions in the hospital and on discharge, and 3) identification of signs of aberrant behavior. For example, the identification of controlled substance prescriptions written by multiple different clinicians can facilitate early identification of potential diversion or evolving or existing opioid use disorder and the opportunity for intervention,²⁸ which may include referral to support services, initiation of medication-assisted treatment, and/or pain specialist consultation when available. Concerns regarding evolving or existing opioid use disorder should prompt further discussion between the clinician and the patient, both to clarify their understanding of their recent prescription history and to discuss concerns for patient safety related to the increased risk of opioid-related adverse effects (including respiratory depression and overdose) among patients with controlled substance prescriptions written by multiple providers. Although such concerns should not automatically preclude the use of opioids for acute pain in the hospital setting, they should be considered in the assessment of whether the benefits of opioid therapy outweigh the risks for a given patient.

4. SHM recommends that clinicians educate patients and families or caregivers about the potential risks and side effects of opioid therapy as well as alternative pharmacologic and nonpharmacologic therapies for managing pain.